Cleveland_Well Abandonment_20230118

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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Justice 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
.�.we Is abandoned:
NCW-2150-A REC,E � E0)
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Justice Well Drilling JAN 1 .8 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name Infora a1 prC^.°�.*^+" 73% powder chlorine
°� !Type of disinfectant used:_ (�
,'0J30G
2.Well Construction Permit#: 173127
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflorown 1 0 oZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Searing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑ Sand Cement Grout M Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery r ;
Injection Well: M For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2 yards
❑Aquifer Storage'and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
_ Pull pump,dorine,dry clay
4.Date well(s)abandoned: 01/11/23
5a.Wellilocation: .., (.
The Broadway Group"LLC for Dollar Gener
Facility/Owner,Name s . ,. ; Facility 10 (if applicable) 8 rtification:
224 Stagecoach Trail 'Lawndale NC 01/11/23
Physical Address,City,and Zip ., %nature of Certified W Co c r.gr.Well Owner. Date ,
Cleveland ,- ,. ,
By signing this forrnrl hereby certify that the well(s) was(were)abandoned in
.County Parcel Identification No.(PIN) accordance with 15A NCAC.02C:0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: }
-(if well.field,,one lat/long is sufficient)' "' 9.Site diagram or additional well details:
35.4756 N -81 .5345 `,I, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)1favailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells:. Submit this form within.30 days of completion-of well
6a.Well 1D4: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 78 M-) 1617 Mail Service Center,Raleigh,NC 27699-1617.
10b.For Iniection Wells:;In addition to sending the form to the address in 10a
6e.Borehole diameter:
24 (in.) above, also submit one copy of this form.within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 55 (ft) Division of Water Resources,Underground Injection Control Program,
ervc en -
' 1636 Mar'1 S� r' e Center,Raleigh NC 27699 1636
6e.Outer,casing-length(if known): 55 00 10c For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also-submit one copy of this form-within.30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length{(if known)' (ft,) abandoned. ,..
'6g.Screen length(if known): 00

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1.Well Contractor Information: WELL ABANDONMENT DET/J S
Gary Justice 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
property)
NCW-2150-A wells abandoned:
P'y�`°�' " � � 180
NC Well Contractor Certification Number R I_.`D E 11 VIE— •� 7b.Approximate volume of water remaining in well(s): (gal.)
Justice Well Drilling BAN - R 7073 FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: I'3% powder chlorine
Ff'�dEy'1 r'r�,�3T�trrki
2.Well Construction Permit#:_173118 rlLyMrK;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown 1 0 oZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check.all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation M Specialty Grout 19 Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1 M/2 ton pea g ravel
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
4 bags type s cement
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(fleating/Cooling Return) ❑Other(explain under 7g)
01/11/23 Pull pump,clorine,camera,fill with gravel
4.Date well(s)abandoned: Then cement
5a.Well location:
The Broadway Group LLC for Dollar Genera
Q�
Facility/Owner Name Facility ID#(if applicable) 8 rtification:
224 Stagecoach Trail Lawndale NC 01/11/23
Physical Address,City,and Zip ignature of Certified W Co c r or Well Owner Date
Cleveland By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has-been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.4772 N -81 .53448 `,1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 305 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 120 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 76 (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fort within 30 days of completion
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): 00 abandoned.
6g.Screen length(if known): (ft.)